1. Intake Case No. State of Wisconsin Circuit Court 2. County Deferred Prosecution Agreement 3. Case Type Delinquency In Need of Protection/Services Ordinance/Civil Law In the interest of: 4. Name of Juvenile 5. Date of Birth 6. Juvenile's Address 7. Date Juvenile Referred An inquiry has been conducted into this matter. It has been determined that at this time neither the interests of the juvenile named above nor of the public require filing of a petition for circumstances relating to §§938.12 to 938.14, Wisconsin Statutes. It is this worker's belief, however, that the facts are sufficient that court action could be sought, and this conclusion is undisputed by the juvenile and parents, guardian or legal custodian. 8. Summary of Undisputed Facts: 9. Obligations - Check all appropriate boxes for any combination of obligations A. Case held open for months or until (Date) . B. No new referrals to intake and/or violations of federal, state or local laws. C. Restitution: $ Payment Terms: (under age 14, $250.00 limit), pay to: Make repairs or provide services agreeable to the victim (under age 14, 40 hour limit): D. Community Service (under age 14, 40 hour limit) Amount: hours Terms: E. Counseling Child Terms: Parent/guardian Family F. Alcohol/Drug Abuse (A.O.D.A) Assessment Not possess alcohol or drugs Submit to drug screens Terms, if any: G. Teen/Youth Court Program H. Curfew: JD-1706, 05/12 Deferred Prosecution Agreement This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 §938.245, Wisconsin Statutes. American LegalNet, Inc. www.FormsWorkFlow.com Deferred Prosecution Agreement Page 2 of 2 Intake Case No. I. Daily school attendance; no unexcused absences; obey school rules: J. No contact with: K. Other specific obligations/conditions: The juvenile and the juvenile's parents, guardian and legal custodian are hereby notified of the right to object at any time to the facts or terms of the deferred prosecution agreement. If there are objections, the worker may alter the terms of the agreement or recommend that a petition be filed. This agreement may be terminated at any time upon the request of the juvenile, juvenile's parents, guardian or legal custodian. If the deferred prosecution agreement is terminated, the worker may recommend to the district attorney or corporation counsel that a petition be filed. If at any time during the period of this agreement the intake worker determines that the stated obligations are not being met, the intake worker may cancel this agreement and recommend that a petition be filed. The district attorney may file a delinquency petition within 20 days of receipt of this agreement. Filing of a petition will cancel this agreement. If a deferred prosecution agreement is canceled because the juvenile's parent, guardian or legal custodian is not meeting the obligations imposed under the agreement, a hearing may be held for the parent, guardian or legal custodian to show good cause for not meeting the obligations. If good cause is not shown, the court may impose a forfeiture not to exceed $1,000. Date Agreement is Effective Date Agreement Terminates Print or Type Names Signatures Date Signed Juvenile Father/Guardian/Legal Custodian Mother/Guardian/Legal Custodian Worker JD-1706, 05/12 Deferred Prosecution Agreement This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 §938.245, Wisconsin Statutes. American LegalNet, Inc. www.FormsWorkFlow.com